High dose chemotherapy and autologous stem cell transplantation for salvage therapy of relapsed /refractory germ cell tumors; a single center experience

PURPOSE

The optimal management of relapsed/refractory germ cell tumors remains unsettled. In this study, we aimed to evaluate the efficacy of high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT) as salvage therapy in patients who progressed after at least one line of cisplatin-based chemotherapy.

METHODS

We retrospectively reported the results of 133 patients who underwent HDCT and ASCT as salvage therapy from 2016 to 2021. Patients received 3 cycles of paclitaxel, ifosfomide and cisplatin (TIP) regimen as induction and 1 cycle of carboplatin 700 mg/m2 on days 1 to 3 plus etoposide 750 mg/m2 on days 1 to 3, followed by ASCT. Demographic and clinicopathological features of patients, the International Germ Cell Cancer Collaborative Group (IGCCCG) risk group at diagnosis, serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (HCG) levels before HDCT, treatment related complications and survival outcomes were recorded.

RESULTS

The median age of the patients was 31 (range 18-62). The median follow-up was 31.1 months (95% CI, 28.9 to 33.3 months). During the median follow-up period, 74 of the 133 patients were still alive, and 63 of these were in complete remission. The median progression-free survival (PFS) was 25.8 months (95% CI, 8.1-43.4 months). The 2-year PFS rate was 50.3% and the 2-year overall survival rate was 60.8%. Variables that remained statistically significant in multivariable analysis and were associated with poor prognosis were mediastinal primary tumor location, presence of brain metastases, and higher AFP and HCG levels at baseline.

CONCLUSION

One course of HDCT and ASCT after induction with TIP is an effective and feasible treatment option for salvage treatment of relapsed/refractory germ cell tumors, with cure rates of up to 60%.

Adrenocortical Cancer in the Real World: A Comprehensive Analysis of Clinical Features and Management from the Turkish Oncology Group (TOG)

INTRODUCTION

Adrenocortical carcinoma (ACC) is a rare yet highly malignant tumor associated with significant morbidity and mortality. This study aims to delineate the clinical features, survival patterns, and treatment modalities of ACC, providing insights into the disease's prognosis.

MATERIALS AND METHODS

A retrospective analysis of 157 ACC patients was performed to assess treatment methodologies, demographic patterns, pathological and clinical attributes, and laboratory results. The data were extracted from the hospital's database. Survival analyses were conducted using the Kaplan-Meier method, with univariate and multivariate analyses being performed through the log-rank test and Cox regression analyses.

RESULTS

The median age was 45, and 89.4% had symptoms at the time of diagnosis. The median tumor size was 12 cm. A total of 117 (79.6%) patients underwent surgery. A positive surgical border was detected in 26 (24.1%) patients. Adjuvant therapy was administered to 44.4% of patients. The median overall survival for the entire cohort was 44.3 months. Median OS was found to be 87.3 months (95% confidence interval [CI] 74.4-100.2) in stage 2, 25.8 (95% CI 6.5-45.1) months in stage 3, and 13.3 (95% CI 7.0-19.6) months in stage 4 disease. Cox regression analysis identified age, Ki67 value, Eastern Cooperative Oncology Group performance status, and hormonal activity as significant factors associated with survival in patients with nonmetastatic disease. In metastatic disease, only patients who underwent surgery exhibited significantly improved overall survival in univariate analyses.

CONCLUSION

ACC is an uncommon tumor with a generally poor prognosis. Understanding the defining prognostic factors in both localized and metastatic diseases is vital. This study underscores age, Ki67 value, Eastern Cooperative Oncology Group performance status, and hormonal activity as key prognostic determinants for localized disease, offering critical insights into the complexities of ACC management and potential avenues for targeted therapeutic interventions.

Treatment outcomes and prognostic factors in patients with driver mutant non-small cell lung cancer and de novo brain metastases

Central nervous system (CNS) metastases can be seen at a rate of 30% in advanced stages for patients with non-small cell lung cancer (NSCLC). Growing evidence indicates the predictive roles of driver gene mutations in the development of brain metastases (BM) in recent years, meaning that oncogene-driven NSCLC have a high incidence of BM at diagnosis. Today, 3rd generation targeted drugs with high intracranial efficacy, which can cross the blood-brain barrier, have made a positive contribution to survival for these patients with an increased propensity to BM. It is important to update the clinical and pathological factors reflected in the survival with real-life data. A multi-center, retrospective database of 306 patients diagnosed with driver mutant NSCLC and initially presented with BM between between November 2008 and September 2022 were analyzed. The median progression-free survival (mPFS) was 12.25 months (95% CI, 10-14.5). While 254 of the patients received tyrosine kinase inhibitor (TKI), 51 patients received chemotherapy as first line treatment. The median intracranial PFS (iPFS) was 18.5 months (95% CI, 14.8-22.2). The median overall survival (OS) was 29 months (95% CI, 25.2-33.0). It was found that having 3 or less BM and absence of extracranial metastases were significantly associated with better mOS and iPFS. The relationship between the size of BM and survival was found to be non-significant. Among patients with advanced NSCLC with de novo BM carrying a driver mutation, long-term progression-free and overall survival can be achieved with the advent of targeted agents with high CNS efficacy with more conservative and localized radiotherapy modalities.

Pembrolizumab With or Without Lenvatinib for First-Line Metastatic NSCLC With Programmed Cell Death-Ligand 1 Tumor Proportion Score of at least 1% (LEAP-007): A Randomized, Double-Blind, Phase 3 Trial

INTRODUCTION

Lenvatinib plus pembrolizumab was found to have antitumor activity and acceptable safety in previously treated metastatic NSCLC. We evaluated first-line lenvatinib plus pembrolizumab versus placebo plus pembrolizumab in metastatic NSCLC in the LEAP-007 study (NCT03829332/NCT04676412).

METHODS

Patients with previously untreated stage IV NSCLC with programmed cell death-ligand 1 tumor proportion score of at least 1% without targetable EGFR/ROS1/ALK aberrations were randomized 1:1 to lenvatinib 20 mg or placebo once daily; all patients received pembrolizumab 200 mg every 3 weeks for up to 35 cycles. Primary end points were progression-free survival (PFS) per Response Evaluation Criteria in Solid Tumors version 1.1 and overall survival (OS). We report results from a prespecified nonbinding futility analysis of OS performed at the fourth independent data and safety monitoring committee review (futility bound: one-sided p < 0.4960).

RESULTS

A total of 623 patients were randomized. At median follow-up of 15.9 months, median (95% confidence interval [CI]) OS was 14.1 (11.4‒19.0) months in the lenvatinib plus pembrolizumab group versus 16.4 (12.6‒20.6) months in the placebo plus pembrolizumab group (hazard ratio = 1.10 [95% CI: 0.87‒1.39], p = 0.79744 [futility criterion met]). Median (95% CI) PFS was 6.6 (6.1‒8.2) months versus 4.2 (4.1‒6.2) months, respectively (hazard ratio = 0.78 [95% CI: 0.64‒0.95]). Grade 3 to 5 treatment-related adverse events occurred in 57.9% of patients (179 of 309) versus 24.4% (76 of 312). Per data and safety monitoring committee recommendation, the study was unblinded and lenvatinib and placebo were discontinued.

CONCLUSIONS

Lenvatinib plus pembrolizumab did not have a favorable benefit‒risk profile versus placebo plus pembrolizumab. Pembrolizumab monotherapy remains an approved treatment option in many regions for first-line metastatic NSCLC with programmed cell death-ligand 1 tumor proportion score of at least 1% without EGFR/ALK alterations.

The efficacy of immunotherapy and chemoimmunotherapy in patients with advanced rare tumors: A Turkish oncology group (TOG) study

INTRODUCTION

The advances in immune checkpoint inhibitors (ICIs) were relatively slow in rare tumors. Therefore, we conducted a multi-center study evaluating the efficacy of ICI monotherapy and the combination of ICIs with chemotherapy (CT) in patients with advanced rare tumors.

METHODS

In this retrospective cohort study, we included 93 patients treated with ICIs for NCI-defined rare tumors from the 12 cancer centers in Turkey. The primary endpoints were the overall response (ORR) and disease control rate (DCR).

RESULTS

The cohort's median age was 56, and 53.8% of the patients were male. The most frequent diagnosis was sarcoma (29%), and 81.7% of the patients were previously treated with at least one line of systemic therapy in the advanced stage. The ORR and DCR were 36.8% and 63.2%, respectively. The germ cell tumors had the lowest ORR (0%), while the Merkel cell carcinoma had the highest ORR to ICIs (57.1%). Patients treated with ICI + ICI or ICI plus chemotherapy combinations had higher ORR (55.2% vs. 27.6%, p = 0.012) and DCR (82.8% vs. 53.4%, p = 0.008). The median OS was 13.47 (95% CI: 7.79-19.15) months, and the six and 12-month survival rates were 71% and 52%. The median duration of response was 16.59 months, and the 12-month progression-free survival rate was 66% in responders. The median time-to-treatment failure was 5.06 months (95% CI: 3.42-6.71). Three patients had high-grade irAEs with ICIs (grade 3 colitis, grade 3 gastritis, and grade 3 encephalitis in one patient each).

CONCLUSION

We observed over 30% ORR and a 13-month median OS in patients with rare cancers treated with ICI monotherapy or ICI plus CT combinations. The response rates to ICIs or ICIs plus CT significantly varied across different tumor types. Responding patients had over 2 years of survival, highlighting a need for further trials with ICIs for patients with rare tumors.

Genetic testing and counseling challenges in personalized breast cancer care: review article with insights from Türkiye

According to current evidence, testing for germline BRCA pathogenic variants in newly diagnosed breast cancer (BC) patients has the potential to reduce the burden of the disease through targeted therapies and secondary prevention. A personalized approach to testing can lead to improved individual outcomes for patients. Despite the proven clinical utility and therapeutic impact of BRCA1/2 tests in shaping therapy for metastatic BC, awareness and access to these tests are limited in many developing countries, including Türkiye. This limitation impacts the healthcare economy as delayed or missed interventions can lead to increased long-term costs. The limited access is mainly due to fear of stigmatization among patients, country-specific legislation and costs, a lack of awareness, vagueness surrounding the tests and access restrictions. This review offers a perspective for policymakers and healthcare providers in Türkiye to establish pathways that integrate the patient experience into comprehensive care pathways and national cancer control plans.

Safety of lorlatinib in ALK-positive non-small-cell lung cancer and management of central nervous system adverse events

The use of tyrosine kinase inhibitors has made a breakthrough in the treatment of non-small-cell lung cancer (NSCLC). Recently, lorlatinib, a third-generation tyrosine kinase inhibitor, has demonstrated significant systemic and intracranial activity in both first-line and subsequent-line therapy in ALK-positive NSCLC patients. In this review, general characteristics of lorlatinib, its efficacy in the treatment of ALK-positive NSCLC patients and the safety of lorlatinib, particularly addressing central nervous system adverse events, are discussed. Management of central nervous system adverse events, which seem to be specific to lorlatinib therapy, is outlined.

Treatment efficacy of ribociclib or palbociclib plus letrozole in hormone receptor-positive/HER2-negative metastatic breast cancer

Background: Ribociclib, palbociclib and abemaciclib are currently approved CDK4/6 inhibitors along with aromatase inhibitors as the first-line standard-of-care for patients with hormone receptor-positive, HER2-negative metastatic breast cancer. Methods: The authors report retrospective real-life data for 600 patients with estrogen receptor- and/or progesterone receptor-positive and HER2-negative metastatic breast cancer who were treated with ribociclib and palbociclib in combination with letrozole. Results & conclusion: The results demonstrated that the combination of palbociclib or ribociclib with letrozole has similar progression-free survival and overall survival benefit in real life for the patient group with similar clinical features. Specifically, endocrine sensitivity may be a factor to be considered in the treatment preference.

Major and minor salivary gland cancers: A multicenter retrospective study

BACKGROUND

Most of the studies on salivary gland cancers are limited for various reasons such as being single-center, small number of patients, including only major or minor SGCs, or only including epidemiological data.

METHODS

A total of 37 medical oncology clinics from different regions of Turkey participated in this retrospective-multicenter study. The analyzed data included clinical and demographical features, primary treatment, metastasis localizations, and treatments and includes certain pathologic features.

RESULTS

The study included data from a total of 443 SGCs. 56.7% was in major salivary glands and 43.3% was in minor salivary glands. Distant metastasis in the major SGCs was statistically significantly more common than in the minor SGCs, locoregional recurrence was statistically significantly more common in the minor SGCs than in the major SGCs (p = 0.003).

CONCLUSIONS

Epidemiological information, metastasis and recurrence patterns, treatment modalities, and survival analysis of the patients over 20 years of follow-up are presented.

Impact of adding pertuzumab to trastuzumab plus chemotherapy in neoadjuvant treatment of HER2 positive breast cancer patients: a multicenter real-life HER2PATH study

AIM

To investigate the pathological complete response (pCR) achieved after neoadjuvant therapy with versus without adding pertuzumab (P) to trastuzumab (H) plus neoadjuvant chemotherapy (NCT) in HER2+ breast cancer (BC) patients in a real-life setting.

METHODS

A total of 1528 female HER2+ BC patients who received NCT plus H with or without P were included in this retrospective real-life study. Primary endpoint was pCR rate (ypT0/Tis ypN0). Clinicopathological characteristics, event-free survival (EFS) time, and relapse rates were evaluated with respect to HER2 blockade (NCT-H vs. NCT-HP) and pCR.

RESULTS

Overall, 62.2% of patients received NCT-H and 37.8% received NCT-HP. NCT-HP was associated with a significantly higher pCR rate (66.4 vs. 56.8%, p < 0.001) and lower relapse (4.5 vs. 12.2%, p < 0.001) in comparison to NCT-H. Patients with pCR had a significantly lower relapse (5.6 vs. 14.9%, p < 0.001) and longer EFS time (mean(SE) 111.2(1.9) vs. 93.9(2.7) months, p < 0.001) compared to patients with non-pCR. Patients in the NCT-HP group were more likely to receive docetaxel (75.0 vs. 40.6%, p < 0.001), while those with pCR were more likely to receive paclitaxel (50.2 vs. 40.7%, p < 0.001) and NCT-HP (41.5 vs. 32.1%, p < 0.001). Hormone receptor status and breast conservation rates were similar in NCT-HP vs. NCT-H groups and in patients with vs. without pCR. Invasive ductal carcinoma (OR, 2.669, 95% CI 1.596 to 4.464, p < 0.001), lower histological grade of the tumor (OR, 4.052, 95% CI 2.446 to 6.713, p < 0.001 for grade 2 and OR, 3.496, 95% CI 2.020 to 6.053, p < 0.001 for grade 3), lower T stage (OR, 1.959, 95% CI 1.411 to 2.720, p < 0.001) and paclitaxel (vs. docetaxel, OR, 1.571, 95% CI 1.127 to 2.190, p = 0.008) significantly predicted the pCR.

CONCLUSIONS

This real-life study indicates that adding P to NCT-H enables higher pCR than NCT-H in HER2+ BC, while pCR was associated with lower relapse and better EFS time.

Treatment options in primary mediastinal B cell lymphoma patients, retrospective multicentric analysis; a Turkısh oncology group study

Introduction and Aim

Primary mediastinal B-cell lymphomas (PMBL) are aggressive B- cell lymphomas. Although the initial treatment models vary in PMBL, appropriate treatment methods are not known. We aim to show real-life data on health outcomes in adult patients with PMBL who received various type of chemoimmunotherapies in Turkey.

Method

We analyzed the data of 61 patients who received treatments for PMBL from 2010 to 2020. The overall response rate (ORR), overall survival (OS) and progression-free survival (PFS) of the patients were evaluated.

Results

61 patients were observed in this study. The mean age of the study group was 38.4 ± 13.5 years. From among them, 49.2% of the patients were female (n = 30). For first-line therapy, 33 of them had received rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) regimen (54%). Twenty-five patients had received rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (DA-EPOCH-R) regimen. The ORR was 77%. The median OS and PFS were as follows: 25 months (95% CI: 20.4-29.4) and 13 months (95% CI: 8.6-17.3), respectively. The OS and PFS at 12 months were 91.3% and 50%, respectively. The OS and PFS at five years were 64.9% and 36.7%, respectively. Median follow-up time period was 20 months (IQR 8.5-38.5).

Conclusion

R-CHOP and DA-EPOCH-R showed good results in PMBL. These remain one of the best determined systemic treatment options for first-line therapy. Also, the treatment was associated with good efficacy and tolerability.

Clinicopathological and survival features of neuroendocrine tumors: A retrospective analysis of 153 cases, our current remarks on a heterogeneous tumor group, and still unmet future expectations

Objective

Neuroendocrine neoplasms (NENs) originate from the diffuse neuroendocrine cell system and constitute a heterogeneous group of tumors exhibiting diverse clinical and biological characteristics. NENs include well-differentiated neuroendocrine tumors (NETs) and poorly differentiated neuroendocrine carcinomas (NECs). In the present study, we performed a retrospective analysis of patients diagnosed with NET to evaluate clinicopathological characteristics, treatment and outcomes.

Material and Methods

Data from 153 patients diagnosed with NET who were treated and followed up at three tertiary care centers from November 2002 to June 2021 were retrospectively evaluated. Clinicopathological and prognostic factors, treatment modalities and survival data were analyzed. Kaplan-Meier analysis was used to assess survival data and comparisons were performed using the logrank test.

Results

Median age (IQR) was 53 (18-80) years. 85.6% of the patients had gastro-entero-pancreatic (GEP)-NET. The primary tumor was resected in 95 patients (62.1%) and metastasectomy were performed in 22 patients (14.4%). Seventy-eight patients received systemic therapy for metastatic disease. Patients were followed up for a median of 22 (IQR = 33.8) months. The estimated one-year and three-year survival rate was 89.8% and 74.4%, respectively. Median progression-free survival (PFS) were 10.1, 8.5, and 4.2 months after first-, second- and third-line therapy, respectively.

Conclusion

The number of systemic treatment options and diagnostic tools for NETs has significantly improved in the last few years. NET classification, which treatment will be more appropriate for which group of patients, the molecular basis of this disease and the development of treatment strategies are open-ended questions that still need to be investigated.

Real-life analysis of treatment approaches and the role of inflammatory markers on survival in patients with advanced biliary tract cancer

OBJECTIVES

Advanced-stage biliary tract cancers (BTC) are rare malignancies with poor prognosis. There are few prospective trials, but several retrospective studies regarding treatment options. In this study, we aimed to investigate the role of systemic inflammatory parameters (SIP) and other possible independent factors that may affect survival and treatment approaches and to determine the benefit of later-line treatments in these patients.

METHODS

A total of 284 patients, initially diagnosed with advanced stage or progressed after curative treatment of BTC, from different oncology centers in Turkey were included in this retrospective study. The prognostic significance of clinicopathological factors, SIPs and treatment options was analyzed.

RESULTS

At a median follow-up of 13 months, the median progression-free survival (PFS) was 6.1 months (95% CI:5.51-6.82), and the median overall survival (OS) time was 16.8 months (95% CI: 13.9-19.6). Treatment choice (p < .001 HR:0.70 CI95% 0.55-0.9), performance status (p < .001 HR:2.74 CI 95% 2.12-3.54) and neutrophil-to-lymphocyte ratio (NLR) (p = .02 HR:1.38 CI 95% 1.03-1.84) were independent prognostic factors for PFS. For OS, the independent prognostic indicators were determined as The Eastern Cooperative Oncology Group Performance Status (ECOG PS) (p < .001 HR:1.78 CI 95% 1.5-2.3), Systemic Immune-inflammation Index (SII) (p < .001 HR:0.51 CI95% 0.36-0.73) and stage at diagnosis (p = .002 HR:1.79 CI 95% 1.24-2.59). Furthermore, second and third line treatments significantly prolonged OS in advanced BTC (p < .001 HR:0.55 CI 95% 0.38-0.79; p = .007 HR:0.51 CI95% 0.31-0.83, respectively).

CONCLUSION

SII and NLR are useful prognostic factors and may be helpful in making treatment decisions. Additionally, second and later-line treatments in advanced BTC have a significant impact on survival under real-life conditions.

The effectiveness and safety of neoadjuvant pertuzumab and trastuzumab in women with locally advanced, inflammatory, or early-stage human epidermal growth factor receptor 2-positive breast cancer: Turkish Oncology Group study

In our study, we aimed to evaluate the pathological response rates and side effect profile of adding pertuzumab to the treatment of HER2+ locally advanced, inflammatory, or early-stage breast cancer. This study was conducted by the Turkish Oncology Group (TOG) with data collected from 32 centers. Our study was multicentric, and a total of 364 patients were included. The median age of the patients was 49 years (18-85 years). Two hundred fifteen (60%) of the cases were hormone receptor/HER2+ positive(ER+ or PR+, or both), and 149 (40%) of them were HER2-rich (ER and PR negative). The number of complete responses was 124 (54%) in the docetaxel+trastuzumab+pertuzumab arm and 102 (45%) in the paclitaxel+trastuzumab+pertuzumab arm, and there was no difference between the groups in terms of complete response. In 226 (62%) patients with complete response, a significant correlation was found with DCIS, tumor focality, removed lymph node, and ER status P < 0.05. Anemia, nausea, vomiting, myalgia, alopecia, and mucosal inflammation were significantly higher in the docetaxel arm, P < 0.05. In our study, no statistical difference was found between the before-after echocardiography values. DCIS positivity in biopsy before neoadjuvant chemotherapy, tumor focality; the number of lymph nodes removed and ER status were found to be associated with pCR. In conclusion, we think that studies evaluating pCR-related clinicopathological variables and radiological imaging features will play a critical role in the development of nonsurgical treatment approaches.

Efficacy of Gemcitabine, Paclitaxel, and Oxaliplatin Protocol in the Treatment of Relapsed or Refractory Germ Cell Tumours

OBJECTIVE

To determine the survival endpoints and treatment-related adverse events after the use of the gemcitabine, paclitaxel, and oxaliplatin (GemPOx) protocol in relapsed/refractory germ cell tumours (GCTs) who had previously received multi-line systemic treatments including high-dose chemotherapy.

STUDY DESIGN

Observational study.

PLACE AND DURATION OF STUDY

Clinic of Medical Oncology, Gulhane School of Medicine, Ankara, Turkey, between January 2017 and August 2021.

METHODOLOGY

Clinical characteristics of adult patients with relapsed/refractory GCTs treated with the GemPOx protocol were recorded from the hospital's patient registry database. Patients without a medical record were not included in the study. Objective response rate (ORR), progression-free survival (PFS), overall survival (OS), one-year PFS rate, one-year OS rate, and treatment-related haematological side effects were determined after GemPOx.

RESULTS

Fifty-three adult patients were included (47 of them were male). Seventy-eight percent had Stage 3 at initial diagnosis. Twenty-four percent of the patients received more than four lines of systemic chemotherapy. Ninety-six percent of the patients received high-dose chemotherapy prior to GemPOx. ORR, which is the sum of the complete and partial response rates, was 69.8%. PFS was determined as 8.5 ± 5.4 months. The one-year PFS rate was 30.3%. OS was 15.9 ± 10.6 months. The one-year OS rate was 72.6%. Febrile neutropenia was observed in 15.1% of the patients.

CONCLUSION

In patients with relapsed/refractory GCTs receiving multi-line systemic chemotherapy, significant PFS and OS are achievable, and a manageable spectrum of haematological side effects is observed with GemPOx.

KEY WORDS

Gemcitabine, Paclitaxel, Oxaliplatin, Germ cell tumour.

Real-life analysis of pathologic complete response with neoadjuvant trastuzumab plus taxane with or without pertuzumab therapy in HER2 positive locally-advanced breast cancer (HER2PATH Study)

e12610

Background: Studies in HER2+ locally-advanced breast cancer (LABC) patients with neoadjuvant dual HER2 blockage therapy demonstrated high rates of pathologic complete response (pCR). This study evaluates neoadjuvant chemotherapy (NCT) plus trastuzumab (H) with or without pertuzumab (P) therapy with a nation-wide real world setting. Methods: In this study, 1528 female HER2+ LABC patients’ data received NCT plus H with or without P were collected retrospectively from 21 centers. Ethics committee approved the study (NCT04765124). Primary end point was pCR rate (ypT0/Tis ypN0 in the current AJCC staging system). Results: Of the 1528, 951 (62.2%) were received NCT-H, 577 (37.8%) were received NCT-HP, follow-up durations were 30 months and 15 months, median ages were similar between 2 groups (47 years, range: 20-81 and 47 years, range 22-88, respectively). According to the menopausal and hormone receptor status 60% and 53.7% of patients were classified as premenopausal, 56% and 57.8% as estrogen receptor positive and 46.2% and 47.2% as progesterone receptor positive respectively at NCT-HP and NCT-H groups. Despite the patients at NCT-HP group mostly received docetaxel (75%), NCT-H group received weekly paclitaxel (59.4%) as taxane (p<0.001). pCR rate for patients treated with NCT-HP was significantly better than that for patients received NCT-H (66.4% vs. 56.8%, respectively, p<0.001) and there were not any statistical difference according to hormone receptor status. Two-years event-free survival (EFS) rates were 93.5% and 93.2% for NCT-HP and NCT-H groups, respectively (p=0.655), however, two years EFS rate was statistically significant in patients who achieved pCR compared to those who did not achieve pCR (95.1% vs. %90.6, p<0.001). There was not any toxicity leading to death. Conclusions: Our analysis of this real world data shows higher rates of pCR than in clinical trials, also adding pertuzumab to NCT-H demonstrates higher pCR rates and EFS rates compared with NCT-H in patients with HER2+ LABC.

Long-term outcome and safety in patients treated with immune checkpoint blockade therapies for urothelial carcinoma: Experience from real-world clinical practice

474

Background: Anti-tumor activity and manageable safety profile of immune checkpoint blockade therapies (ICT) have been demonstrated in previous clinical trials in patients with metastatic urothelial carcinoma. To the best of our knowledge, very limited real-life data is available with the long follow-up time that confirms the durable antitumor activity and safety of ICT. In this study, we reported the real-life results of 56 months follow-up data of urothelial carcinoma patients who were treated with ICT. Methods: Metastatic urothelial carcinoma patients treated with at least one course of ICT included in the study. The primary endpoint was the overall response rate (ORR); secondary endpoints were overall survival (OS), progression-free survival (PFS), duration of the ICT treatment, and safety. Median follow-up, PFS, and OS were estimated by using the Kaplan-Meier method. Results: Data of 185 eligible patients were analyzed, 11.9% of these patients received the ICT as the first line, 76.8 % as the second line, and 11.3 % as the third or more line of treatment. The median age of the patients was 66 years, and 156 (84.3%) were male (37-86). The majority of patients (93.5%) had ECOG PS scores of 0–1 and primary tumor in the bladder was predominant (86.7%). The median follow-up time was 47(1.15-56) months. The complete response rate to ICT, partial response rate, and ORR were 10.3% (n = 19), 19.5% (n = 36), and 29.8% (n = 55), respectively. The median duration of response was 33.1 months (95% CI, 16.5–49.7). Of the fifty-five patients who responded to treatment, 28 (51%) had an ongoing response at the time of the analysis. Median PFS and OS was 3.8 (2.6–5.1) months and 8.9 (6.8–11.1) months, respectively. 56-month PFS and OS rate was 9.2% and 11.4%, respectively. 56-month PFS and OS rate for CR and PR was 56.2% and 20%, respectively. Fifty-nine percent of patients experienced a treatment-related adverse event of any grade, and 32 (17.3%) of patients had a grade 3–4 treatment-related adverse event. Because of treatment-related side effects, treatment was discontinued in 8 (4.3%) patients and adverse event that required systemic steroid use was reported in only 13 (7%) patients. Four patients (2.2%) died due to treatment-related causes. Conclusions: This 56-month analysis of real-world data confirms the durable response and long-term survival with ICT in metastatic urothelial carcinoma patients. The safety profile was consistent with prior reports, and no new safety signals emerged.

Surgical, pathological and clinical features of advanced collorectal cancers with metastasectomy. "Onco-Colon Turkey Registry" real-life data

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Background: The contribution of metastasectomy to progression-free survival (PFS) and overall survival (OS) in patients (pts) with advanced stage colorectal cancer has been demonstrated in clinical trials. However, clinical trials may not represent the efficacy of treatment given to the whole population in daily practice, therefore evaluation of real-life data is needed. Methods: The demographic, pathological and clinical characteristics of 1064 RAS wild type pts were recorded in 28 centers in Turkey between January 2016 and March 2019 as part of the Onco-Colon Registry Program ( NCT04757311 ). Metastasectomy was performed in 169 patients (15.9%). In this study, pts with and without metastasectomy were compared in terms of demographic, histopathological and clinical features and treatment results. Results: Median follow-up time was 24 months(mos) (1-74), median age was 59 years (30-81). 32.5% of the pts were women. The proportion of pts with primary right colon was determined to be 16.8%. Synchronous metastasis was detected in 76.3% of those who underwent metastasectomy. Isolated liver metastasectomy was performed in 85.8% of the pts. It has been shown that 21.1% of the pts have MSI-H and 23.3% have a mucinous component. Metastasectomy was performed after conversion therapy in 54.8% of pts. In the patient group who underwent metastasectomy after medical treatment, the median time between the beginning of treatment and metastasectomy was found to be 7 mos (2-34). When the patient characteristics were compared, no significant difference was found between the groups with and without metastasectomy (p > 0.05). The median PFS (mPFS) was 13.5 mos in the group that underwent metastasectomy and 9.9 mos in the group that was not performed (p < 0.0001; HR: 0.63 (95% CI: 0.51-0.77). The median OS (mOS) was 47.3 mos in the group that underwent metastasectomy and 24.3 mos in the group without metastasectomy (p < 0.0001; HR: 0.36 (95% CI: 0.27-0.48). Conclusions: The significant contribution of metastasectomy on mPFS and mOS was shown in this reallife data based trial, where no difference was found in terms of general participation characteristics. In daily practice, prolonged mPFS and mOS emerges as pts who are followed-up radiologically at regular intervals from the beginning and who are appropriate for surgery have the chance of metastasectomy.

Efficacy of high dose chemotherapy in adult patients with relapsed or refractory ewing sarcoma

Background: A rare condition in adults, Ewing sarcoma (EWS) has no standard treatment during the relapse–refractory period. In our study, we aimed to identify the treatment-related side effects of high-dose chemotherapy (HDC) and salvage autologous stem cell transplantation (ASCT) in adult patients with relapsed or refractory EWS and their survival rates. Materials and Methods: In a retrospective study, we recorded the clinical characteristics of patients with relapsed or refractory EWS treated with HDC in the hospital’s patient registry to determine their objective response rate (ORR), progression-free survival (PFS), 6-month PFS rate, overall survival (OS), 6-month OS rate, transplantation-related mortality (TRM) and treatment-related side effects. Results: In our sample of 29 patients (72.4% male), the mean age was 26.41 years (SD = 9.35). The most common primary tumour site was the lower extremities (31%), 69% of patients had lung metastases, and 48.1% had undergone surgical resection, adjuvant radiotherapy and chemotherapy. The ORR to HDC was 31%. Median PFS (IQR) was 5.35 (6.79) months (95% confidence interval = 4.23–8.28), whereas the 6-month PFS rate was 38.9%. Median OS (IQR) was 9.46 (14.45) months (95% confidence interval = 8.52–15.82), whereas the 6-month OS rate was 68.1%. Mortality from HDC or other causes occurred in five patients within the first 100 days after ASCT. Grade 3 febrile neutropenia and thrombocytopenia were present in all patients until engraftment following ASCT. Conclusion: Amongst adults with relapsed or refractory EWS, HDC has successful survival and response rates and a manageable side-effects profile.

High-dose Chemotherapy Response in Adults with Relapsed/Refractory Small Round Cell Tumours

OBJECTIVE

To demonstrate the treatment responses, survival analysis, and treatment-related mortality characteristics of high-dose chemotherapy (HDC) in patients with relapsed/refractory Ewing sarcoma (ES), osteosarcoma, rhabdomyosarcoma (RMS) and medulloblastoma (MB).

STUDY DESIGN

Observational study.

PLACE AND DURATION OF STUDY

Department of Medical Oncology, University of Health Sciences, Gulhane School of Medicine, from January 2016 and April 2020.

METHODOLOGY

Clinical features and follow-up data of relapsed/refractory ES, osteosarcoma, RMS and MB patients treated with HDC were recorded from the patients' registration database of the hospital. Patients <16 years and those whose medical records were not available were excluded. Progression-free survival (PFS), one-year overall survival (OS) rates and treatment-related mortality (TRM) after the HDC were determined. Ifosfamide, carboplatin and etoposide (HD-ICE) were used as the HDC protocol in all patients.

RESULTS

Thirty-seven adult patients were included. PFS was determined as 2.70 ± 0.97 months, 11.57 ± 3.63 months, 3.47 ± 0.44 months and 2.96 ± 0.91 months, for ES, MB, RMS and osteosarcoma, respectively. One-year OS rate was 44.8 ± 14.8% for ES; 75 ± 15.8% for MB. In ES, PFS was found to be better in males than females (p = 0.025). No patient died during HD-ICE. Mortality was observed most frequently in the RMS in the first 100 days (25%).

CONCLUSION

HD-ICE treatment may be an option in relapsed/refractory small round cell tumours (SRCT). Significant progression-free survival can be achieved in patients who received at least two lines of treatment, with acceptable treatment-related mortality. Key Words: Small round cell tumours, Ewing sarcoma, Osteosarcoma, Rhabdomyosarcoma, Medulloblastoma, High-dose chemotherapy, Autologous stem cell transplantation.

Immunogenicity and safety of the CoronaVac vaccine in patients with cancer receiving active systemic therapy

Aim: To evaluate the immunogenicity and safety of the CoronaVac vaccine in patients with cancer receiving active systemic therapy. Methods: This multicenter, prospective, observational study was conducted with 47 patients receiving active systemic therapy for cancer. CoronaVac was administered as two doses (3 μg/day) on days 0 and 28. Antibody level higher than 1 IU/ml was defined as 'immunogenicity.' Results: The immunogenicity rate was 63.8% (30/47) in the entire patient group, 59.5% (25/42) in those receiving at least one cytotoxic drug and 100% (five of five) in those receiving monoclonal antibody or immunotherapy alone. Age was an independent predictive factor for immunogenicity (odds ratio: 0.830; p = 0.043). Conclusion: More than half of cancer patients receiving active systemic therapy developed immunogenicity.

Economic burden of lung cancer in Turkey: a cost of illness study from payer perspective

BACKGROUND

This study was designed to estimate economic burden of lung cancer in Turkey from payer perspective based on expert panel opinion on practice patterns in clinical practice.

METHODS

In this cost of illness study, direct medical cost was calculated based on cost items related to outpatient visits, laboratory and radiological tests, hospitalizations/interventions, drug treatment, adverse events and metastasis. Indirect cost was calculated based on lost productivity due to early retirement, morbidity and premature death resulting from the illness, the value of lost productivity due to time spent by family caregivers and cost of formal caregivers.

RESULTS

Cost analysis revealed the total per patient annual direct medical cost for small cell lung cancer to be €8772), for non-small-cell lung cancer to be €10,167. Total annual direct medical cost was €497.9 million, total annual indirect medical cost was €1.1 billion and total economic burden of lung cancer was €1.6 billion. Hospitalization/interventions (41%) and indirect costs (68.6%) were the major cost drivers for total direct costs and the overall economic burden of lung cancer, respectively.

CONCLUSIONS

Our findings indicate per patient direct medical costs of small cell lung cancer and non-small-cell lung cancer to be substantial and comparable, indicating the substantial economic burden of lung cancer in terms of both direct and indirect costs. Our findings indicate that hospitalization/interventions cost item and indirect costs were the major cost drivers for total direct costs and the overall economic burden of lung cancer, respectively. Our findings emphasize the potential role of improved cancer prevention and early diagnosis strategies, by enabling cost savings related to drug treatment and metastasis management cost items, in sustainability of cancer treatments.

Clinical presentation and course of the novel coronavirus disease 2019 in patients with various types of cancer: A retrospective case-control analysis of an experienced cancer center in Turkey

Objective

Cancers have been reported to worsen the clinical course of coronavirus disease 2019 (COVID-19) infection. We aimed to demonstrate the real-life data on health outcomes in COVID-19-infected cancer patients.

Materials and Methods

We analyzed the data of 43 COVID-19-infected cancer patients in our COVID-19 clinics between March 25, 2020, and May 9, 2020, retrospectively.

Results

We determined that 1051 patients were followed up with COVID-19 infection and 43 (4%) of them were cancer patients. The mean age of the patients was 64.3 ± 12.3 years. Lung cancer is the most common cancer type among the patients (23.2%). Dyspnea (51.2%) was the most common symptom in the first admission. Typical ground-glass consolidation or patchy appearance with peribronchial thickening resembling bronchopneumonia on high-resolution computed tomography (HRCT) was present in 29 (67.4%) patients. COVID-19 was diagnosed in 14 (32.5%) patients based on reverse transcriptase-polymerase chain reaction analysis of nose-throat swab samples without any sign of lung involvement on HRCT. Total mortality of the COVID-19 infection was 46.5% (n = 20). Presence of heart disease (hazard ratio [HR]: 3.5; 95% confidence interval [CI]: 1.29-9.4), previous surgeries to the respiratory system (HR: 6.95; 95% CI: 1.29-27.7), and presence of dyspnea at admission (HR: 4; 95% CI: 1.31-12.3) were statistically significantly associated with death (P = 0.01, 0.02, and 0.01, respectively).

Conclusion

Our practices supported that cancer patients were more affected by COVID-19 disease than the normal population. However, our findings can not be generalized due to being retrospective and single centered study, Also, we did not compare the findings with noncancer patients with COVID19 disease.

The association between antibiotic use and survival in renal cell carcinoma patients treated with immunotherapy: a multi-center study

BACKGROUND

Immunotherapy improves overall survival (OS) in the second and later lines of renal cell carcinoma (RCC) treatment. Recent studies have suggested that antibiotic (ATB) use either shortly before or after the start of immunotherapy could lead to decreased OS. Herein, we evaluate the impact of ATB use on OS in RCC patients treated with nivolumab in a multi-center cohort from Turkey.

METHODS

The data of 93 metastatic RCC patients treated with nivolumab in the second line or later were retrospectively collected from 6 oncology centers. Previous treatments, sites of metastases, International Metastatic RCC Database Consortium risk classification, and ATB use in the three months before (-3) or three months after (+3) the start of immunotherapy were recorded together with survival data. The association of clinical factors with OS and progression-free survival (PFS) was analyzed with univariate and multivariable analyses.

RESULTS

The median age was 61 (interquartile range 54-67), and 76.3% of the patients were male. The median OS of the cohort was 23.75 ± 4.41, and the PFS was 8.44 ± 1.61 months. Thirty-one (33.3%) patients used ATBs in the 3 months before (-3) or 3 months after (+3) nivolumab initiation. In the multivariable analyses, ATB exposure (HR: 2.306, 95% confidence interval [CI]: 1.155-4.601, P = 0.018) and the presence of brain metastases at the baseline (HR: 2.608, 95% CI: 1.200-5.666, P = 0.015) had a statistically significant association with OS, while ATB exposure was the only statistically significant parameter associated with PFS (HR: 2.238, 95% CI: 1.284-3.900, P = 0.004).

CONCLUSION

In our study, patients with ATB exposure in the 3 months before or 3 months after the start of immunotherapy had shorter OS. Our findings further support meticulous risk-benefit assessments of prescribing ATBs for patients who are either receiving or are expected to receive immunotherapy.

The temporal evaluation of RAS and BRAF mutation by liquid biopsy at progression after bevacizumab combinations in patients with metastatic colorectal cancer (mCRC)

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Background: Expanded RAS analysis is essential for the selection of biologic agents in mCRC. RAS mutations indicates anti-EGFR unresponsiveness. In this study, we aimed to investigate RAS and BRAF mutations by liquid biopsy at progression in patients with RAS mutant mCRC. Methods: Sixty patients with mCRC who harbored tissue RAS mutations were prospectively analyzed between July 2019 and April 2020. All the patients treated with chemotherapy plus bevacizumab combinations . The plasma samples of the patients were analyzed after progression of bevacizumab combinations. RAS mutation profile was evaluated in plasma using Idylla PCR-based molecular diagnostics method, which enables rapid detection of common mutations in RAS and BRAF genes in circulating tumor DNA (ctDNA). Kaplan-Meier method was used for survival analysis and log-rank test was performed for comparison of groups. Results: The median age of the patients was 60 years (IQR:35-83 years) and female was (n=23, 38.3%). Primary tumor was located in the left colon in 81.7% of all patients. There were 95.0% KRAS and 5% NRAS mutations in baseline tissue biopsy. As a result of liquid biopsy after progression, 55.0% of the patients had KRAS, 3.3% NRAS and 3.3% had BRAF mutations. The RAS mutation detected in 58.3% of the patients. While there was no significant difference in terms of clinicopathological features between wild type (RAS/BRAF) and mutant type (RAS/BRAF) determined by liquid biopsy, the overall survival (OS) of the wild type group was significantly longer than mutant group (43.8 vs. 20.4 months, p= 0.002). Conclusions: This study demonstrated that there may be changes in RAS/BRAF mutation from plasma analysis after progression in patients with mCRC. Since better survival in the patient group with wild type was detected compared to the RAS concordance group, the evaluation of RAS mutation status at the time of progression may be important in terms of disease prognosis and treatment options.

Real-world treatment outcomes from nationwide ONCO-colon Turkey registry in RAS wi̇ld-type patients treated with biologics first-line metastatic colorectal cancer

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Background: Efficacy of anti-angiogenic and anti-EGFR agents has been demonstrated metastatic colorectal cancer (mCRC). Real-world evidence is especially important to detect the findings of patients outside of clinical trials. It complements together with clinical trials. However, there are a few studies that evaluated these treatments with biologics in the real-world setting. Recognizing the change that has occurred over the years will also shed light on future approaches. Therefore, we aimed to investigate the real-world data of patients with RAS-wild type mCRC. Methods: Medical records from 28 centers were collected for patients diagnosed with RAS wild-type mCRC between January 2016 and April 2019 and were included into the study. Histopathological, molecular and clinical characteristics of the patients were recorded. The treatment duration, response rate, progression-free survival and safety results were determined. Also, changes over the years were compared. Patients were compared according to the first-line biological treatments as anti-EGFR group (Group A and B) (panitumumab and cetuximab) and anti-VEGF group (group C). Results: Patients with KRAS mutant type were 43,6% and 6.1% patients were NRAS mutant type. A total of 1064 patients with documented RAS wild-type status were evaluated. 33%, 37% and 30% of all first line patients were treated with regimen including panitumumab, cetuximab and anti-VEGF, respectively. The median follow-up time was 24 (1-59) months. Median age was 61 (17-88) years. Thirty-five percent of the patients were female. Twenty percent of the patients had a right-sided colon tumor. Patients received median 6 cycles of treatment. Also, responded patients received median 6 cycles of treatment as maintenance treatment with biologics plus fluoropyrimidine. Overall response rate was 46,4%, 41,9% and 41,5% in A, B and C group respectively (p = 0,170). The median OS was 26, 27, and 23 months in A, B and C group respectively (p = 0.044). The median PFS of the patients in first-line setting that received panitumumab, cetuximab and bevacizumab were 11.6 (SE:0,6; 95% CI: 10.4-12.7), 11.0 (SE:0,5; 95% CI: 9.9-12.0), and 9.6 (SE:0,4; 95% CI: 8.8-10.4) months respectively (p = 0.012). In univariate analysis, female gender (p = 0.030), left sided tumors(p = 0.001), ECOG performance status (PS) 0-1 (p = 0.001), normal CEA level at initial diagnosis(p = 0.001) and treatment with anti-EGFR agents(p = 0.016) were found as favorable factors. PS 0-1 and normal CEA level at initial diagnosis were found as independent prognostic factors in multivariate analysis (p = 0.049, p = 0.031 respectively). Conclusions: This analysis of real-world data confirms the comparable efficacy of anti-EGFR agents in RAS-wild type mCRC. However, anti-EGFR treatment provides PFS and OS advantage when compared with anti-VEGF treatment in these patients.

Nivolumab as second-line treatment and beyond for metastatic renal cell carcinoma: A real-life experience from Turkish Oncology Group Kidney Cancer Consortium (TKCC) Database

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Background: Immune checkpoint inhibitors (ICIs) started a new era in the treatment of metastatic renal cell carcinoma (mRCC). CheckMate-025 and CheckMate-214 trials established the effect of ICIs in the second-line and upfront therapy of mRCC, respectively. This study aimed to share a real-life experience regarding nivolumab in the second-line treatment and beyond in mRCC Methods: We retrospectively searched the Turkish Oncology Group Kidney Cancer Consortium (TKCC) database, which is the multicenter registry system, and extracted patients treated with nivolumab in the second line and beyond. The patients treated with nivolumab plus targeted therapy or ipilimumab were excluded. The primary endpoint was overall survival (OS). The secondary endpoints were response rates and safety. Results: A total of 134 patients were included in this study. The median age at the starting of nivolumab treatment was 61 years (Inter Quartile Range (IQR):55-67). Three out of four patients were male. One hundred four patients (78%) had previous nephrectomy. The majority of patients had clear-cell pathology (83%). Thirteen patients (10%) had sarcomatoid features. According to International Metastatic RCC Database Consortium (IMDC) risk score, seventy patients (52%) were in the intermediate and poor prognostic group. The previous drugs administered in each line before nivolumab are shown in the table below. The number of patients treated with nivolumab was 63(47%), 45(33%), 17(13%), and 9(7%) in the second-, third-, fourth-, and fifth-line setting, respectively. The median OS was 34 months (95% Confidence Interval (CI): 24.1-43.8)) with the 15 months (IQR:5-26) median follow-up. Objective response rate (ORR) and disease control rate (DCR) was 33% and 57%, respectively. The most common grade 3 or higher AEs leading to treatment discontinuation were pneumonitis (%1.4) and colitis (<%1). Conclusions: In compliance with the CheckMate-025 trial results, nivolumab improved OS for mRCC patients treated in the second line and beyond. The median OS was slightly higher in our study than the CheckMate-025 (34 months versus 25.8 months). It may be associated with the patient population in our study. Patients up to the fifth-line setting of mRCC treatment were included in this study. Of note, there was no additional safety concern for nivolumab. [Table: see text]

The Effect of Primary Surgery in Patients with De Novo Stage IV Breast Cancer with Bone Metastasis Only (Protocol BOMET MF 14-01): A Multi-Center, Prospective Registry Study

BACKGROUND

More evidence shows that primary surgery for de novo metastatic breast cancer (BC) prolongs overall survival (OS) in selected cases. The aim of this study was to evaluate the role of locoregional treatment (LRT) in BC patients with de novo stage IV bone only metastasis (BOM).

METHODS

The prospective, multicenter registry study BOMET MF14-01 was initiated in May 2014. Patients with de novo stage IV BOM BC were divided into two groups: those receiving systemic treatment (ST group) and those receiving LRT (LRT group). Patients who received LRT were further divided into two groups: ST after LRT (LRT + ST group) and ST before LRT (ST + LRT group).

RESULTS

We included 505 patients in this study; 240 (47.5%) patients in the ST group and 265 (52.5%) in the LRT group. One hundred and thirteen patients (26.3%) died in the 34-month median follow-up, 85 (35.4%) in the ST group and 28 (10.5%) in LRT group. Local progression was observed in 39 (16.2%) of the patients in the ST group and 18 (6.7%) in the LRT group (p = 0.001). Hazard of death was 60% lower in the LRT group compared with the ST group (HR 0.40, 95% CI 0.30-0.54, p < 0.0001).

CONCLUSION

In this prospectively maintained registry study, we found that LRT prolonged survival and decreased locoregional recurrence in the median 3-year follow-up. Timing of primary breast surgery either at diagnosis or after ST provided a survival benefit similar to ST alone in de novo stage IV BOM BC patients.

IPS-3 Validation in 1012 cases with classical hodgkin lymphoma

The aim of this study is to validate the IPS-3 scoring system as a prognostic indicator in 1012 patients with advanced stage classical Hodgkin Lymphoma (cHL) treated by doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD). According to the IPS-3 scoring system only 3.5 % had high risk and 50.8 % had low risk disease disease and 45.8 % of the cases had intermediate risk disease. Each factors of IPS-7 and IPS-3 scoring systems (age, sex, stage hemoglobin, albumin, lymphocyte count and white cell count) were found to be significant for overall survival (OS) and progression free survival (PFS) according to univariate analyses. Two different multivariate Cox analyses were performed for OS and PFS including the IPS-3/ IPS-7 scoring system parameters. Among 7 risk factors of IPS scoring system, gender and albumin were not found as independent risk factors for both OS and PFS according to cox regression model. But all parameters such as age, stage and hemoglobin those included in IPS-3, were found to be independent significant risk factors for both models obtained for OS and PFS. The results of the study shows that the IPS-3 scoring system can be used as a prognostic indicator in ABVD treated patients in every day practice which is more easily calculate according to the IPS-7.

"Swords and Shields" against COVID-19 for patients with cancer at "clean" and "pandemic" hospitals: are we ready for the second wave?

Purpose

COVID-19 will continue to disrupt the diagnosis-treatment process of cancer patients. Dr. Abdurrahman Yurtaslan Ankara Oncology Hospital has been considered as a ‘non-pandemic’ center (‘clean’) in Ankara, the capital city of Turkey. The other state hospitals that also take care of cancer patients in Ankara were defined as ‘pandemic’ centers. This study aimed to evaluate hospital admission changes and the precautionary measures in clean and pandemic centers during the pandemic. The effect of these measures and changes on COVID-19 spreading among cancer patients was also evaluated.

Methods

The patients admitted to the medical oncology follow-up, new diagnosis, or chemotherapy (CT) outpatient clinics during the first quarter of pandemic period (March 15–June 1, 2020) of each center were determined and compared with the admissions of the same frame of previous year (March 15–June 1, 2019). COVID-19 PCR test results in clean and pandemic centers were compared with each other. Telemedicine was preffered in the clean hospital to keep on follow-up of the cancer patients as ‘noninfected’.

Results

In the clean hospital, COVID-19-infected patients that needed to be hospitalized were referred to pandemic hospitals. COVID-19 test positivity rate was eight-fold higher for outpatient clinic admissions in pandemic hospitals (p < 0.001). The number of patients admitted new diagnosis outpatient clinics in both clean and pandemic hospitals decreased significantly during the pandemic compared with the previous year.

Conclusion

We consider that local strategic modifications and defining ‘clean’ hospital model during infectious pandemic may contribute to protect and treat cancer patients during pandemic.

Yttrium-90 (Y-90) resin microsphere therapy for patients with unresectable hepatocellular carcinoma. Identification of successful treatment response predictors and patient selection

AIM

Selective intraarterial radionuclide therapy (SIRT) with Yttrium-90 (Y-90) resin microspheres has been applied for hepatocellular carcinoma (HCC) lately. The aim of this study is to present our clinical experience of radiomicrosphere therapy in the treatment of unresectable HCC and determine the proper cases who could benefit from this therapy according to response results yielded by initial staging and control imaging modalities.

METHODS

We administered 43 Y-90 microsphere therapy to 34 patients with unresectable HCC (twice in 9 patients). Patients with histopathologically confirmed HCC having a life expectancy of ≥3 months; Child A-B, Okuda stage 1-2 and BCLC stage A-B-C classifications were included in the study. The patients were divided into two groups: Group A consisted of 29 patients who responded to Y-90 therapy (complete response, partial response and stable disease), Group B 5 of non-responders (progressive disease). Predefined parameters were evaluated for response to SIRT and compared between two groups.

RESULTS

We found a significant decrease in platelet and lymphocyte counts one month after therapy (p=0.02, p=0.01, respectively). On control imaging tests performed 3 months later, we observed complete response in 19% (n=6), partial response in 44% (n=15), stable disease in 25% (n=8) and progressive diease in 12% (n=5) of the patients. Mean overall survival (OS) was 19 (median value: 14) months.

CONCLUSIONS

Y-90 microsphere therapy is a safe and effective treatment option for the patients with unresectable HCC without any serious side effect. Mean tumor dose delivery and lack of bilobar disease seem the best predictors for treatment success.

KEY WORDS

Selective intraarterial Radionuclide therapy, Yttrium-90, hepatocellular carcinoma.

Effectiveness of bendamustine in relapsed or refractory lymphoma cases: a Turkish Oncology Group study

INTRODUCTION

We aimed to investigate the efficacy and side effects of bendamustine in relapsed/refractory lymphoma patients in Turkey.

MATERIAL AND METHODS

In this retrospective study, we included relapsed/refractory Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) patients who underwent multiple lines of chemotherapy. The primary endpoint was to determine the objective response and toxicity.

RESULTS

Ninety-nine patients with a median age of 59.8 years were included in the study. Eighty-one patients had NHL (follicular lymphoma: 10, diffuse large B-cell lymphoma: 27, mantle-cell lymphoma: 18, marginal zone lymphoma: 9, small lymphocytic lymphoma/chronic lymphocytic leukemia: 17) and 18 patients had HL. The patients had previously received a median of three lines of chemotherapy (range: 2-8) except autologous stem cell transplantation (ASCT); 19 patients (HL: 11, NHL: 8) had undergone ASCT. The objective response rate (ORR) was 74.3%, the complete response rate was 57% (= 53), and the partial response rate was 16.6% ( = 19). The overall survival (OS) rate at 1 year was 74.6%. The progression-free survival (PFS) rate at 1 year was 62.5%. The most common side effects were lymphopenia, anemia and neutropenia. Side effects which were observed as grade 3 and higher levels were lymphopenia (14.1%), neutropenia (10.1%) and fatigue (7.1%).

CONCLUSIONS

Objective response rate of bendamustine was found to be 74.3% in relapsed/refractory HL and NHL patients. It appears to be an effective option as a salvage treatment for patients who have previously received multiple lines of therapy.

Treating relapsed and refractory metastatic germ cell tumours with high-dose chemotherapy with carboplatin and etoposide and autologous haematopoietic stem cell transplantation

INTRODUCTION AND AIM

To demonstrate the real-life data about patients who underwent AHSCT due to GCT.

METHODS

Between November 2016 and April 2020, 64 patients who received CE as high-dose chemotherapy for AHSCT in the Gulhane Education and Research Hospital were included in the study. Sixty-one patients received one AHSCT with CE chemotherapy regimen. Survival data and clinical characteristics were evaluated retrospectively.

RESULTS

The mean age of the patients were 31.9 ± 9 (min-max:18-55). With a median follow-up of 10.7 ± 8.7 months, the 1-year progression-free survival (PFS) rate was 57.8%, and the 1-year overall survival rate was 77.5%. Median overall survival (OS) and progression-free survival (PFS) times were 21.5 ± 1.8 (95% CI: 14.5-33.4) and 20 ± 2 months, respectively. The response rate was 72%. There were three treatment-related deaths.

CONCLUSION

This sizeable single-centre study shows that patients with relapsed metastatic GCT are curable by CE as high dose chemotherapy plus AHSCT with reliable toxicity even for a single cycle.

Tolvaptan treatment in hyponatremia due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH): effects on survival in patients with cancer

PURPOSE

To investigate the clinical outcomes of patients with hyponatremia who received supportive treatment or tolvaptan plus supportive treatment and the effects of treatment and other variables on overall survival METHODS: This study included oncology patients who were hospitalized at two oncology centers between January 1, 2016 and December 31, 2019 for hyponatremia (sodium levels < 135 mEq/L) and who received tolvaptan plus supportive treatment (n = 22) or supportive treatment only (n = 42).

RESULTS

The median age of all the patients was 59 years (range 26-85) and 64.1% of the patients were male. There was no statistically significant difference between patients in the tolvaptan plus supportive treatment (TpST) group and the supportive treatment only (ST) group in terms of gender and age (p > 0.05). In the TpST group, recovery days of the hyponatremia after treatment and the length of hospital stay was shorter and hyponatremia symptoms and hospital complications were less frequent compared to the ST group (p < 0.05). There was no significant difference between the TpST group and the ST group in terms of overall survival (OS). OS was shorter in men who were non-responders to hyponatremia treatment and had recurrent hyponatremia. Multivariable analysis showed that normal sodium levels after treatment decreased the risk of death.

CONCLUSION

In the treatment of hyponatremia in cancer patients, TpST was found to have more positive effects on blood sodium levels, length of hospital stay, hospital complications, and hyponatremia symptoms compared to ST. A decreased risk of death was observed in patients with normal sodium levels after treatment.

Does primary tumor localization has prognostic importance in seminoma patients?: Turkish Oncology Group Study

PURPOSE

The purpose of this study was to determine whether primary tumor localization may be a risk factor for relapse and survival in seminomatous germ cell tumors (GCT) patients.

METHODS

In our study, 612 seminomatous GCT patients diagnosed in 22 centers between 01.01.1989 and 03.02.2019 were retrospectively evaluated. Patient interview information, patient files and electronic system data were used for the study.

RESULTS

The primary tumor was localized in the right testis in 305 (49.9%) patients and in 307 (50.1%) in the left testis. Mean age of the patients was 36 years (range 16-85±10.4). The median follow-up period was 47 months (1-298). Recurrence was observed in 78 (12.7%) patients and 29 (4.7%) died during the follow-up period. Four-year overall survival (OS) was 95.4% and 4-year progression-free survival (PFS) was 84.5%. The relationship between localization and relapse was significant in 197 patients with stage 2 and stage 3 (p=0.003). In this patient group, 41 (20.8%) relapses were observed. Thirty (73.2%) of the relapses were in the right testis and 11 (26.8%) in the left testis. Four-year OS was 92.1% in patients with right tumor; and 98.7% in patients with left tumor (p=0.007). When 612 patients were evaluated with a mean follow-up of 4 years, there was a 6.6% survival advantage in patients with left testicular tumor and this difference was significant (p=0.007).

CONCLUSION

Survival rates of patients with primary right testicular localization were worse compared with left testicular localization, and relapse rates were higher in stage 2 and 3 patients with right testicular localization.

What is the optimal high-dose treatment following autologous stem cell transplantation in relapsed or refractory germ cell cancer: a retrospective comparison of high-dose ICE and high-dose CE

PURPOSE

Testicular cancer is the most commonly diagnosed solid organ malignancy in 15 to 35 year-old men with 1% incidence among all malignancies. Sixty percent of patients with mild and poor-risk factors need additional treatments. Starting in 1980s, high dose chemotherapy regimens (HDCT) that were not applicable before due to hematological toxicity have been brought into use, and survival and cure possibility have increased. To date, no randomized trial has been conducted to demonstrate superiority of high-dose chemotherapy protocols used for autologous stem cell transplantation (ASCT). Our study aims to compare two commonly used HDCT regimens for a long period, with real-life data.

METHODS

Approval for thiss retrospective study was obtained from the ethics committee of Gülhane Training and Research Hospital. Fifty refractory testicular cancer patients above 18 years were treated with HDCT and ASCT at Gülhane Training and Research Hospital (January 2011-July 2018).

RESULTS

Fifty metastatic, refractory testicular carcinoma patients with a median age of 34 were included in the study. Ninety per cent of the cases had stage III disease at diagnosis. Except for 8 patients (16%) at mild risk group, all the other patients were at high risk. CE was used as salvage treatment for half of the patients and ICE was used for the other half. Four patients responded completely and 30 responded partially to ASCT. Post transplantation median progression-free survival (PFS) was 22 months. Median overall survival (OS) in the general population was 223.4 months (76.1-370.7). Although there was a difference in OS between chemotherapy groups, the difference was not statistically significant. The mean duration of engraftment in patients treated with CE was 11.2 ± 2.3 days, while in patients receiving ICE it was 15.5 ± 2.1 days. This difference between chemotherapy groups was statistically significant (p<0.001).

Neutrophil-lymphocyte ratio as a prognostic factor for survival in patients with advanced renal cell carcinoma (Turkish Oncology Group Study)

BACKGROUND

To describe the prognostic value of neutrophil-lymphocyte ratio and its effect on survival in in patients with advanced renal cell carcinoma.

METHODS

We retrospectively analyzed 331 patients. The cut-off value of neutrophil-lymphocyte ratio was specified as "3" which is mostly close-and also clinically easily applicable-to the median neutrophil-lymphocyte ratio level of our study group. High group is identified as neutrophil-lymphocyte ratio >3 (n = 160) and low group is identified as neutrophil-lymphocyte ratio ≤3 (n = 163).

RESULTS

A total of 331 (with 211 male and 120 female) patients were enrolled to study. The median age of the patients was 58. The International Metastatic RCC Database Consortium risk score is calculated for the 72.8% (n = 241) of the study group and among these patients, favorable, intermediate, and poor risk rates were 22, 45.2, and 32.8%. The total usage of tyrosine kinase inhibitors reached 78% of the patients. The median overall survival was 32 months versus 11 months in the neutrophil-lymphocyte ratio low and high groups, respectively (HR: 0.49 (95% CI 0.37-0.65), p < 0.001).

CONCLUSION

In conclusion, the pre-treatment value of elevated neutrophil-lymphocyte ratio might be a predictor of poor overall survival in advanced renal cell carcinoma patients.

The Pan-Cancer Landscape of Coamplification of the Tyrosine Kinases KIT, KDR, and PDGFRA

PURPOSE

Amplifications of receptor tyrosine kinases (RTKS) are therapeutic targets in multiple tumor types (e.g. HER2 in breast cancer), and amplification of the chromosome 4 segment harboring the three RTKs KIT, PDGFRA, and KDR (4q12amp) may be similarly targetable. The presence of 4q12amp has been sporadically reported in small tumor specific series but a large-scale analysis is lacking. We assess the pan-cancer landscape of 4q12amp and provide early clinical support for the feasibility of targeting this amplicon.

EXPERIMENTAL DESIGN

Tumor specimens from 132,872 patients with advanced cancer were assayed with hybrid capture based comprehensive genomic profiling which assays 186-315 genes for all classes of genomic alterations, including amplifications. Baseline demographic data were abstracted, and presence of 4q12amp was defined as 6 or more copies of KIT/KDR/PDGFRA. Concurrent alterations and treatment outcomes with matched therapies were explored in a subset of cases.

RESULTS

Overall 0.65% of cases harbored 4q12amp at a median copy number of 10 (range 6-344). Among cancers with >100 cases in this series, glioblastomas, angiosarcomas, and osteosarcomas were enriched for 4q12amp at 4.7%, 4.8%, and 6.4%, respectively (all p < 0.001), giving an overall sarcoma (n = 6,885) incidence of 1.9%. Among 99 pulmonary adenocarcinoma cases harboring 4q12amp, 50 (50%) lacked any other known driver of NSLCC. Four index cases plus a previously reported case on treatment with empirical TKIs monotherapy had stable disease on average exceeding 20 months.

CONCLUSION

We define 4q12amp as a significant event across the pan-cancer landscape, comparable to known pan-cancer targets such as NTRK and microsatellite instability, with notable enrichment in several cancers such as osteosarcoma where standard treatment is limited. The responses to available TKIs observed in index cases strongly suggest 4q12amp is a druggable oncogenic target across cancers that warrants a focused drug development strategy.

IMPLICATIONS FOR PRACTICE

Coamplification of the receptor tyrosine kinases (rtks) KIT/KDR/PDGFRA (4q12amp) is present broadly across cancers (0.65%), with enrichment in osteosarcoma and gliomas. Evidence for this amplicon having an oncogenic role is the mutual exclusivity of 4q12amp to other known drivers in 50% of pulmonary adenocarcinoma cases. Furthermore, preliminary clinical evidence for driver status comes from four index cases of patients empirically treated with commercially available tyrosine kinase inhibitors with activity against KIT/KDR/PDGFRA who had stable disease for 20 months on average. The sum of these lines of evidence suggests further clinical and preclinical investigation of 4q12amp is warranted as the possible basis for a pan-cancer drug development strategy.

The relationship between prognostic nutritional index and treatment response in patients with metastatic renal cell cancer

Introduction and aim

To investigate the effect of the prognostic nutritional index on treatment response and survival in patients with metastatic renal cell cancer.

Methods

We retrospectively analyzed the treatment modalities; the demographic, clinical and pathological features of 396 patients with RCC and prognostic nutritional index. Based on the median value, patients were grouped as having low and high prognostic nutritional index values. Kaplan-Meier method was used for survival analysis, and Cox-regression analysis was used for multivariate analysis.

Results

The median overall survival was 39 months (95% CI 26.1–51.8), 28 months (95% CI 17.9–38) and 7 months (95% CI 4.7–9.2) in patients with favorable, intermediate and poor International Metastatic Renal Cell Carcinoma Database Consortium risk group, respectively. The difference between the groups was statistically significant (p < 0001). Overall survival was 11 months (95% CI 7.5–14.5) in the low-prognostic nutritional index (prognostic nutritional index ≤38.5) group, and 41 months (95% CI 30.5–51.4) in the high prognostic nutritional index (prognostic nutritional index >38.5) group (p < 0.001). In Cox regression analysis, Eastern Cooperative Oncology Group performance score (HR: 2.5), time to systemic treatment (HR: 1.7) and prognostic nutritional index (HR: 1.8) were associated with overall survival.

Conclusion

In patients with renal cell cancer, prognostic nutritional index is closely related to survival and has prognostic significance.

Endpoints in oncology clinical trials

In oncology clinical trials, many different endpoints can be used as primary or secondary endpoints. Advances in cancer treatment have provided longer survival outcomes, particularly in certain types of cancer. Overall survival is accepted as the gold standard endpoint for demonstrating clinical benefit; however, it is associated with some disadvantages such as requirement of long-term follow-up, requirement of higher number of patients, and high cost. Thus, the question "what is the most appropriate endpoint in clinical trials?" comes to mind. The present review discusses the endpoints in oncology clinical trials.

Pertuzumab, trastuzumab and taxane-based treatment for visceral organ metastatic, trastuzumab-naïve breast cancer: real-life practice outcomes

PURPOSE

In this study, we aimed to describe the real-life practice outcomes of pertuzumab-trastuzumab-taxane (PTT) combination in visceral organ metastatic, trastuzumab-naive breast cancer (BC) patients.

METHODS

This study was conducted by Turkish Oncology Group and included 317 patients' data from 36 centers.

RESULTS

Median age was 51 (22-82). Median PFS was 28.5 months, while median OS was 40.3 months. Patients with brain metastases (n: 13, 4.1%) had worse PFS (16.8 m vs. 28.5 m; p = 0.002) and OS (26.7 m vs. 40.3 m; p = 0.009). Patients older than 65 years of age (n: 42, 13.2%) had significantly lower OS results (19.8 m vs. 40.3 m; p = 0.01). Two hundred sixty-eight patients (86.7%) received docetaxel while 37 patients (11.7%) received paclitaxel. PFS and OS were similar between taxane groups. In eight patients (2.5%), 5-40% ejection fraction decrement from baseline was detected without any clinical sign of heart failure.

CONCLUSIONS

Our RLP trial included only visceral metastatic, trastuzumab-naïve BC patients including cases with brain involvement who received PTT combination in the first-line treatment. Regardless of negative prognostic characteristics, our results are in parallel with pivotal trial. Further strategies for brain metastasis should be developed to improve outcomes despite encouraging results with PTT treatment. Taxane selection can be personalized and endocrine maintenance may further improve outcomes after taxanes were discontinued. To our knowledge, this is the largest scale real-life clinical practice study of pertuzumab-trastuzumab-taxane therapy to date.

Is there a role of high dose chemotherapy and autologous stem cell transplantation in the treatment of Ewing's sarcoma and osteosarcomas?

Although osteosarcomas are rare tumors, they are the most common primary bone tumors in children and adolescents younger than 20 years with a remarkable male predominance. Ewing's sarcoma (ES) is the second most common primary bone tumor in children and adolescents. The preferred actual treatment modality for osteosarcoma patients is neoadjuvant chemotherapy followed by complete surgical excision and adjuvant chemotherapy including agents such as doxorubicin, cisplatin, ifosfamide, and high-dose methotrexate which are widely used and accepted as being efficacious treatment strategies in osteosarcoma patients. Conventional treatments have increased overall survival (OS) rates in osteosarcoma and ES, but not as enough as desired. High dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT) may be beneficial in some subgroup of ES, including children with partial response to conventional chemotherapy and with poor-risk as well as metastatic ES. HDC and ASCT remain as a clinical option in patients with ES, but it is considered as an experimental treatment approach for patients with osteosarcoma. In this review, we discussed the current approach and role of HDC and ASCT in the treatment of osteosarcoma and ES and focused on the current literature data evaluating the treatment outcomes of some sub-groups of high risk patients.

A Review of Allogeneic Hematopoietic Stem Cell Transplantation in Metastatic Breast Cancer

Breast cancer (BC) has a high mortality rate and metastatic BC is almost incurable despite hormonal therapy and chemotherapy. The second and third lines of chemotherapies usually yield transient responses and the median survival is generally as low as 18-24 months. Autologous and allogeneic hematopoietic stem cell transplantation (HSCT) have been extensively investigated in this setting. The presence of immune mediated anti-tumor effects referred to as graft-versus-tumor (GvT) effects after allogeneic HSCT among patients with solid tumors have been clearly defined. The advantages of allogeneic HSCT over autologous HSCT for metastatic BC are i) cancer-free graft and ii) immune-mediated GvT effects mediated by human leukocyte antigen compatible donor T-cells. In conclusion, a GvT effect does exist against metastatic BC and play a key role in tumor response. This review aims to describe the background, rationale, and clinical results of allogeneic HSCT as a potential alternative treatment in metastatic BC.